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Wondering if anyone has any ideas that might help me.
Today I saw an 11yr old girl age champion for sprinting 100m and 200m who complains of left Achilles tendon pain, lower third only, proximal to insertion and localised to the medial aspect of the tendon. The pain only occurs when running the 200m, she is pain free when running 100m and when playing other sports ie netball. Foot type shows underdeveloped calcaneus compared to her forefoot, lunge test WNL, strong unilateral toe raises, moderate bowing of Achilles in stance with some mtj instability but nothing excessive.
She is currently wearing an Asics spike running shoe.
She has previously used heel cushions which did not reduce her pain.
She also has a very nasty plaster allergy so I'm unable to trial strapping the foot.
As an initial treatment plan I have suggested some eccentric strengthening for her Achilles
Could her pain be due to accelerating on the bend in the 200m which in turns increases strain on the medial aspect of the Achilles tendon on her inside foot? And if so is there any way to decrease the load on her Achilles due the acceleration phase of the 200m sprint?
Thanks

Forefoot varus wedge to see if you can get immediate change during sprint itself.


But getting the daily orthotic stuff right (which probably wont include a FF var wedge) for the remainder of the week.




Ron
Physiotherapist (Masters) & Podiatrist

Ron, why don't you patent a forefoot varus wedge with some sort of servo motor in it, so it stays up around the bend and then becomes flat along the straight .... shades of Beno Nigg's preferred pathway model ...

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Good point.

The aim is to help the symptoms during the bend, but not to the detriment of the home straight.






Ron
Physiotherapist (Masters) & Podiatrist

Put a 3-5 degree varus forefoot wedge into the left track spike first of all to see if this eliminates the pain in the 200 meter event. If it does, which it likely will, then either use this wedge in both the 100 meter and 200 meter sprints, or have her use a removable insole or second pair of spikes with the varus wedge only for her 200 m races.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Craig

You might have had your tongue in your cheek but in reference to your comment, I have just seen a material that changes its properties depending on the rate of load it experiences, becoming stiffer under rapid loading.
Might be the solution?

Phil

Just a thought:

Am I right in saying the curve of the track goes to the left on an athletics track, therefore as she is leaning to the left on this curve the tendo achilles may be under a greater strain due to the fact that she is leaning to that side and sprinting?

Does the pain happen during every time she runs the curve? Does she train at all on this curve? If so you could get her to run the other way around the track (obviously not during competition), that may reduce overall stressing by changing the way she has to lean, I know athletes tend to do training 50% in each direction.

What are the exact pain symptoms? Does she get pain only during the activity or afterwards also?

My tuppence worth, which is probably worth ha'penny.

S

The pain only occurs when running the 200m not when playing netball ( which she plays 4 days per week) or when competing in the 100m.... so therefore I concluded in may be as you said the fact that when she is running the bend in the 200m her weight has shifted to the LHS and increased strain on the left Achilles. The pain prevents her from finishing her training sessions.

I hadn't thought to suggest training running clockwise so that might be a great way to have more symmetrical loading of her Achilles.

It's a couple of weeks before I get to see her again so I will trial a FF varus wedge in her spike for when she is training in the usual direction and will suggest trialling running clockwise to see if this reduces load on her left Achilles.

Thanks

From experience with track athletes in my stable (predominantly 100 --> 400m runners), I have found left achilles pain seems to pop up especially during our speed endurance phase of running (incorporating a lot of 150's --> 300's, thus increase bend running), so I guess this may be similar to what your client may be experiencing?

Athletes in my stable have responded well to about 3 degree forefoot varus wedging using a about a 350 density EVA during trainings, but prefer not to wear during race day....following race day rituals etc, they prefer to be free from a wedge on race day.

Another thought is looking at the base of the spike plate (depending which Asics spike she has), but I have found placing 4mm spikes under the lateral side of the spike plate, 5 - 6mm in the centre and 7 -8mm spikes under the medial side, essentially creating an inversion like force when running on synthetic tracks. Athletes have found this both comfortable and useful when reducing symptoms such as achilles tendonopathy and MTSS, especially on days where they compete in multiple events.

However, if she wears the Asics Japan lightning, this may tough, as they have 3 fixed spikes!

Also in training, it wouldn't hurt to run trainings (even warm up run throughs) clockwise. Of memory, when our Sydney 4x400m Aussie team were training, i believe clockwise bend work was classed as essential work when in the peak of the training to reduce overuse injuries?

Warm Regards,


Nitta

According to Leech and Brower (1970) they suggested that running on a track increased the adduction angle on the leg turning into the bend on a track, thus increasing pronation. Increased adduction moment will also increase not only the whiplash effect of the achilles tendon but the eccentric contraction of gastroc / soleus to reduce pronation moment (Schepsis A, Jones H, Haas A (2002) Achilles Tendon Disorders in Athletes. Am J Sports Med, vol. 30 no. 2 287-305)


See Fig Attached as .JPG sourced from Rasmussen (1974) Shin Splints: Definition and treatment Am. J. Sports Med. 2; 111.

This is from some of work ive been doing for my MSc and is very interesting to find out how different people approach this problem.

Indeed i have used forefoot posting as suggested by Dr Kirby and others and it does produce good results. As Michael suggests its very difficult to get track athletes to wear the orthoses in their spikes shoes for a prolonged period as they dont seem to like it (Not sure why) so i get them to do the majority of their track training in normal running shoes and then spikes for the final timed stuff and then also during competition. Again good points made by others like running around the track clockwise instead of anti clock wise.

Attached Images

adduction angle.jpg (46.9 KB, 145 views)

Great news! A 5 degree forefoot wedge was issued one month ago for the left spike and was only to be used during the 200m races. Patient returned today for follow up appointment and reported a complete resolution of pain in the left achilles and also reported a recent PB in the 200m since the addition of the forefoot wedge.
Thanks Atlas , Kirby and co

Very nice.. Well done! Thanks for keeping us informed..

Sam

How long before the IOC put this in the 'performance enhancing footwear' category and it gets banned?

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

Thanks for keeping us up to date on this interesting case. This is a classic example of how using the Tissue Stress Theory of treating mechanically-based pathologies of the foot and lower extremity can greatly simplify the ability of the clinician to make good treatment decisions to solve seemingly complex patient complaints with relatively simple mechanical methods.

1. Anatomically identify injured stuctural component: Achilles tendon.

2. Determine mechanical factors and type of tissue stress causing injury: Running left handed turns increases subtalar joint (STJ) pronation moment on left foot likely causing increase in tensile stress in lateral fibers of Achilles tendon.

3. Make treatment decision that will decrease tissue stress in injured tissue, allow healing, prevent other injuries and will optimize gait function: Add varus forefoot wedge to left forefoot only since, A) in sprinting the forefoot is the only part of foot to contact the ground, B) forefoot varus wedge will decrease external STJ pronation moments from ground reaction force during turns and decrease tensile stress on injured portion of Achilles tendon.

When podiatry students complain that they are confused in biomechanics by being taught multiple theories so that they don't know how to treat such patients as above, I lke to ask the teachers who like to teach multiple theories the following question: how would you treat this case using the principles advocated by the Neutral Position Theory or Sagittal Plane Facilitation Theory or any other lesser known theory??

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Glad to hear it has resolved. Something I was wondering is if the adduction from the curve would interfere with normal quad function which may decrease knee extension in toe off and put far more strain on the gastroc?

Hi Kevin, "lateral", a typo, it is medial, isn't it?, thanks, mark c

Mark:

Thanks for the correction...yes......it should have read "medial fibers of Achillles tendon".

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin and all;

While I don't disagree with your treatment plan I do think that others, such as DBannerman and Matthew Malone, are including a step that you are leaving out.

The knee position in this instance is very important to recognize in relation to what the foot/ankle complex is doing and in what it may be allowed to do.

As Matt's picture shows so well, there is tremendous body lean during cornering. This create's a functionally long leg that will often have to prolong or increase flexion at the knee joint to allow contact from the contralteral limb.

This increased or prolonged knee flexion which can and will lead to an increase in knee abduction angle will allow for prolonged pronation at the STJ and, as you state, an increase in the pronation moment.

I disagree with your statement in part 3. (A) where you state, " in sprinting the forefoot is the only part of foot to contact the ground, ". I think plenty of recent high speed video and published literature is debunking that claim, especially in a longer sprint such as a 200m race.

Instead, I think it would be more appropriate to reason that the heel lifts early in these limbs during early midstance primarily due to prolonged or increased knee flexion to aid in properly positioning the knee at the expense of the foot.

I think this is another case where you might consider that the sagittal motion of the foot at the AJ, midfoot and MPJ's has been fully utilized and all that is left is compensation in the sagittal plane at the knee.

Once the knee stays or increases its flexion then abduction rotation can be prolonged or increased adn STJ pronation can do so as well.

Adding a FF wedge, or an entire varus wedge in some instances, should eliminate the need for this proximal compensation because the medial FF loads ealier in midstance stailizing the medial column. Since the heel won't have to lift as early the knee will not have to flex as long or as much. The end benefit is that the STJ will not have to have prolonged pronation and the achilles no longer hurts.

I would add as well something that I think others were alluding to, in that if the knee stays in a prolonged or increased flexed postion with, or due to early heel lift, that will interrupt the normal DFion of the AJ that needs to occur for proper gastroc/soleal energy return. I think this as well as the STJ postion adn other compensations may be as much or more responsible for the patients pain. I think it reasons that the medial achilles may be stressed from the muscle/tendon having to maintain a workload without any aid from the normal energery return of a AJ that cannot DF as much as it needs to on a regular basis.

Cheers!
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce:

OK. I should have said that the rearfoot only contacts the ground for a few milliseconds, if at all, during sprinting instead of "in sprinting the forefoot is the only part of foot to contact the ground". The bottom line is that putting any type of foot orthosis into a set of racing spikes for a sprinter will probably not only be mechanically useless for a sprinter that spends the vast majority of their time on the ground only on their forefoot (not their rearfoot), but will also add unnecessary mass to the shoe/foot that will tend to slow the sprinter.

In addition, the best way to understand the mechanical effects of body lean during racing the 200 m outdoor races or longer is not by thinking that you are creating, as you say, "a functional long leg" or by worrying about knee flexion angles. Rather, the best way to view the mechanical effects of sprinting around a turn is to consider the center of mass (CoM) of the body and why the CoM must be positioned toward the inside the sprint turn, rather than directly over the feet, as normally occurs during standing, walking or running in straight lines.

A sprinter in the 200 m race must reposition their center of mass (CoM) toward the inside of the turn in order to prevent the medially-directed shearing ground reaction force (GRF) vector acting on their plantar feet, which acts as the centripetal force which is necessary to push the body into a curved path around the turn, from accelerating their CoM medially or laterally away from a position that would be out of the line of action of the superiorly and medially directed GRF vector acting on their plantar foot. The medially-directed shearing GRF (i.e. centripetal force) will directly counterbalance the laterally directed force acting on the sprinter's CoM (i.e. centrifugal force) that comes from the sprinter choosing to run in a curved path around the turn (i.e. not continuing to run in a straight line).

Therefore, as a result of this necessary centripetal force which comes from the medially directed GRF acting on the sprinter's plantar feet during the 200 m turn, the body lean that the sprinter must assume creates an increased frontal plane angulation of the lower extremities relative to the ground that will cause an increased magnitude of subtalar joint (STJ) pronation moment on the left foot and an increased magnitude of STJ supination moment on the right foot during the sprint turn. The increased STJ pronation moment on the left foot during the turn will create increased internal tensile stress in the medial fibers of the Achllles tendon on the left foot which will lead to increased chance of a tensile stress injury to the medial fibers of the Achilles tendon in the left foot of these athletes.

The simple forefoot varus wedge that I recommended for this athlete 4.5 months ago:

and the resultant mechanical effect of this varus forefoot wedge:

support the practical use of this type of treatment and the validity of the mechanical analysis I have provided above in the many sprinters I have treated over the last quarter century with similar pathologies.

Thanks for your comments on this subject, Bruce, and also thanks for what you have done for the quality of sports medicine education and training over the last few years for the podiatric profession.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Kevin;

thanks for the reply and the kind words, I appreciate it.

I agree the the body positioning is key here. I agree with the treatment plan as well, and it worked! Thanks for the agreement on the heel contact too.

I agree with the stress to the medial column of the plantar fascia and continuing to the achilles medially as well.

The only thing I can say on the STJ positioning is that often in your publications you have argued for your medial skive technique due to the position of the talus and that the only area for creating a supination moment around the STJ was at the heel. In other words, depending on the patients STJ position a medial FF wedge could actualy add to the pronation moment at the STJ in many cases, thought not necessarily this patients. I think you will agree with me here, but I've been wrong on this before!

My point on this is that while I don't disagree on the treatment plan / scheme, I do have great reserve in agreeing with your explanation of why it worked.

I still feel that the early loss of heel contact adn then impending delay in transition thru midstance adn late midstance will cause the primary stress at the Achilles insertion in this case. A re-orientation of the Foot adn or Forefoot thru the use of the varus wedging will help stabilize the midfoot and medial column in midstance and help to position the foot much better in relation to the CoM as you said and in relation to the GRF's.

This varus positioning I think will help the midfoot to resist DFion and resist the internal rotation of the midstance that this extremely canted foot had to tolerate. I think this is more likely to delay the early heel off and to allow the knee to stay extended, or less flexed potentially, again decreasing the internal forces of the lower leg adn their effects on the STJ.

There is a combintion of both theories to some extent I"m sure. My point being is is more than just sagittal plane or STJ positional theory in action. I think we will all appreciate this more and more if we get a chance to follow thru with Craigs discussion on orthotic prescription variables.

I am still curious as to your thoughts on the possible increase in STJ pronation moments from the FF varus wedging thought!

cheers;
Bruce

__________________
Bruce E. Williams, D.P.M.
Breakthrough Podiatry

Bruce:

I don't believe that I ever said the only way to create a subtalar joint (STJ) supination effect from an orthosis was to have the orthosis press on the medial calcaneus. What I have said is, due to the principle of STJ rotational equilibrium, a STJ supination effect from a foot orthosis may occur either due to an increase in magnitude of STJ supination moment and/or a decrease in magnitude of STJ pronation moment. In other words, you may increase the net STJ supination moment acting on the foot by simply reducing the magnitude of STJ pronation moment.

In the case of the varus forefoot wedge in a sprinter, even if the STJ is medially deviated so that all the metatarsal heads are lateral to the STJ axis, if the varus forefoot wedge shifts the center of pressure (CoP) more medially on the forefoot, ground reaction force (GRF) will now be producing decreased external STJ pronation moment when compared to running without the varus forefoot wedge. This decrease in external STJ pronation moment produced by the varus forefoot wedge in the sprinter will, effectively, be producing more tendency for the STJ to supinate and less tendency for the STJ to pronate, or in other words, produce a STJ supination effect.

One must also remember that GRF acting on the plantar forefoot is directly converted to STJ pronation and/or supination moments on the STJ/rearfoot. Therefore, even in the sprinter that never contacts the rearfoot to the ground, GRF still causes direct pronation/supination moments across the STJ even though GRF doesn't contact the plantar calcaneus. This is a very important concept that I have described in detail in my previous papers and books on the subject of how GRF affects the moments across the STJ axis.

Bruce, good to see you back contributing again on Podiatry Arena.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************